Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

PROSTATECTOMY WITH MCC

Facility

$22,564.30

Service Code	MSDRG 665
Min. Negotiated Rate	$22,564.30
Max. Negotiated Rate	$22,564.30
Rate for Payer: Hawaii Medical Service Association Commercial	$22,564.30

PROSTATECTOMY WITHOUT CC/MCC

Facility

$15,927.74

Service Code	MSDRG 667
Min. Negotiated Rate	$15,927.74
Max. Negotiated Rate	$15,927.74
Rate for Payer: Hawaii Medical Service Association Commercial	$15,927.74

Prosthetic Training Charges

Facility

$260.00

Service Code	HCPCS 97761 GP,CQ
Hospital Charge Code	8111695
Hospital Revenue Code	420
Min. Negotiated Rate	$221.00
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$169.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: MDX Hawaii PPO	$252.20

Prosthetic Training Charges

Facility

$260.00

Service Code	HCPCS 97761 GP,CQ
Hospital Charge Code	8111695
Hospital Revenue Code	420
Min. Negotiated Rate	$17.70
Max. Negotiated Rate	$252.20
Rate for Payer: AlohaCare Medicaid	$130.00
Rate for Payer: AlohaCare Medicare	$130.00
Rate for Payer: Cash Price	$169.00
Rate for Payer: Cash Price	$169.00
Rate for Payer: Devoted Health Medicare	$143.00
Rate for Payer: Hawaii Medical Service Association Medicare	$130.00
Rate for Payer: Hawaii Western Management Group Commercial	$247.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Humana Medicare	$130.00
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: Kaiser Permanente Medicaid	$132.60
Rate for Payer: Kaiser Permanente Medicare	$130.00
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: Ohana Health Plan Medicaid	$130.00
Rate for Payer: Ohana Health Plan Medicare	$130.00
Rate for Payer: UnitedHealthcare Medicaid	$17.70
Rate for Payer: UnitedHealthcare Medicare	$130.00
Rate for Payer: University Health Alliance Commercial	$145.60

protamine 50 mg/5 ml vial [HHSC]

Facility

$62.28

Service Code	HCPCS J2720
Hospital Charge Code	2500709
Hospital Revenue Code	636
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$60.41
Rate for Payer: AlohaCare Medicaid	$31.14
Rate for Payer: AlohaCare Medicaid	$38.42
Rate for Payer: AlohaCare Medicare	$38.42
Rate for Payer: AlohaCare Medicare	$31.14
Rate for Payer: Cash Price	$40.48
Rate for Payer: Cash Price	$40.48
Rate for Payer: Cash Price	$49.95
Rate for Payer: Cash Price	$49.95
Rate for Payer: Devoted Health Medicare	$34.25
Rate for Payer: Devoted Health Medicare	$42.26
Rate for Payer: Hawaii Medical Service Association ABD	$1.64
Rate for Payer: Hawaii Medical Service Association ABD	$1.64
Rate for Payer: Hawaii Medical Service Association Medicare	$38.42
Rate for Payer: Hawaii Medical Service Association Medicare	$31.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.64
Rate for Payer: Hawaii Western Management Group Commercial	$59.17
Rate for Payer: Hawaii Western Management Group Commercial	$73.00
Rate for Payer: Health Management Network Commercial	$65.31
Rate for Payer: Health Management Network Commercial	$52.94
Rate for Payer: Humana Medicare	$38.42
Rate for Payer: Humana Medicare	$31.14
Rate for Payer: Kaiser Permanente Commercial	$56.05
Rate for Payer: Kaiser Permanente Commercial	$69.16
Rate for Payer: Kaiser Permanente Medicaid	$39.19
Rate for Payer: Kaiser Permanente Medicaid	$31.76
Rate for Payer: Kaiser Permanente Medicare	$31.14
Rate for Payer: Kaiser Permanente Medicare	$38.42
Rate for Payer: MDX Hawaii PPO	$60.41
Rate for Payer: MDX Hawaii PPO	$74.53
Rate for Payer: Ohana Health Plan Medicaid	$38.42
Rate for Payer: Ohana Health Plan Medicaid	$31.14
Rate for Payer: Ohana Health Plan Medicare	$31.14
Rate for Payer: Ohana Health Plan Medicare	$38.42
Rate for Payer: UnitedHealthcare Medicaid	$46.10
Rate for Payer: UnitedHealthcare Medicaid	$37.37
Rate for Payer: UnitedHealthcare Medicare	$31.14
Rate for Payer: UnitedHealthcare Medicare	$38.42
Rate for Payer: University Health Alliance Commercial	$45.40
Rate for Payer: University Health Alliance Commercial	$56.01

protamine 50 mg/5 ml vial [HHSC]

Facility

$62.28

Service Code	HCPCS J2720
Hospital Charge Code	2500709
Hospital Revenue Code	250
Min. Negotiated Rate	$52.94
Max. Negotiated Rate	$60.41
Rate for Payer: Cash Price	$40.48
Rate for Payer: Cash Price	$49.95
Rate for Payer: Health Management Network Commercial	$52.94
Rate for Payer: Health Management Network Commercial	$65.31
Rate for Payer: Kaiser Permanente Commercial	$56.05
Rate for Payer: Kaiser Permanente Commercial	$69.16
Rate for Payer: MDX Hawaii PPO	$74.53
Rate for Payer: MDX Hawaii PPO	$60.41

Protein C Activity FSI

Facility

$158.00

Service Code	HCPCS 85303
Hospital Charge Code	8118022
Hospital Revenue Code	305
Min. Negotiated Rate	$134.30
Max. Negotiated Rate	$153.26
Rate for Payer: Cash Price	$102.70
Rate for Payer: Health Management Network Commercial	$134.30
Rate for Payer: Kaiser Permanente Commercial	$142.20
Rate for Payer: MDX Hawaii PPO	$153.26

Protein C Activity FSI

Facility

$158.00

Service Code	HCPCS 85303
Hospital Charge Code	8118022
Hospital Revenue Code	305
Min. Negotiated Rate	$13.84
Max. Negotiated Rate	$153.26
Rate for Payer: AlohaCare Medicaid	$79.00
Rate for Payer: AlohaCare Medicare	$79.00
Rate for Payer: Cash Price	$102.70
Rate for Payer: Cash Price	$102.70
Rate for Payer: Devoted Health Medicare	$86.90
Rate for Payer: Hawaii Medical Service Association ABD	$19.11
Rate for Payer: Hawaii Medical Service Association Commercial	$17.30
Rate for Payer: Hawaii Medical Service Association Medicare	$79.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.07
Rate for Payer: Hawaii Western Management Group Commercial	$13.84
Rate for Payer: Health Management Network Commercial	$134.30
Rate for Payer: Humana Medicare	$79.00
Rate for Payer: Kaiser Permanente Commercial	$142.20
Rate for Payer: Kaiser Permanente Medicaid	$80.58
Rate for Payer: Kaiser Permanente Medicare	$79.00
Rate for Payer: MDX Hawaii PPO	$153.26
Rate for Payer: Ohana Health Plan Medicaid	$79.00
Rate for Payer: Ohana Health Plan Medicare	$79.00
Rate for Payer: UnitedHealthcare Medicaid	$19.11
Rate for Payer: UnitedHealthcare Medicare	$79.00
Rate for Payer: University Health Alliance Commercial	$35.74

Protein Electrophoresis, Serum Reflex Immunofixation FSI

Facility

$127.00

Service Code	HCPCS 84165
Hospital Charge Code	8118024
Hospital Revenue Code	301
Min. Negotiated Rate	$10.74
Max. Negotiated Rate	$123.19
Rate for Payer: AlohaCare Medicaid	$63.50
Rate for Payer: AlohaCare Medicare	$63.50
Rate for Payer: Cash Price	$82.55
Rate for Payer: Cash Price	$82.55
Rate for Payer: Devoted Health Medicare	$69.85
Rate for Payer: Hawaii Medical Service Association ABD	$14.84
Rate for Payer: Hawaii Medical Service Association Commercial	$13.43
Rate for Payer: Hawaii Medical Service Association Medicare	$63.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.58
Rate for Payer: Hawaii Western Management Group Commercial	$10.74
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Humana Medicare	$63.50
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: Kaiser Permanente Medicaid	$64.77
Rate for Payer: Kaiser Permanente Medicare	$63.50
Rate for Payer: MDX Hawaii PPO	$123.19
Rate for Payer: Ohana Health Plan Medicaid	$63.50
Rate for Payer: Ohana Health Plan Medicare	$63.50
Rate for Payer: UnitedHealthcare Medicaid	$14.84
Rate for Payer: UnitedHealthcare Medicare	$63.50
Rate for Payer: University Health Alliance Commercial	$27.77

Protein Electrophoresis, Serum Reflex Immunofixation FSI

Facility

$127.00

Service Code	HCPCS 84165
Hospital Charge Code	8118024
Hospital Revenue Code	301
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$82.55
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: MDX Hawaii PPO	$123.19

Protein Electrophoresis, Serum (SPEP) FSI

Facility

$127.00

Service Code	HCPCS 84165
Hospital Charge Code	8118023
Hospital Revenue Code	301
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$82.55
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: MDX Hawaii PPO	$123.19

Protein Electrophoresis, Serum (SPEP) FSI

Facility

$127.00

Service Code	HCPCS 84165
Hospital Charge Code	8118023
Hospital Revenue Code	301
Min. Negotiated Rate	$10.74
Max. Negotiated Rate	$123.19
Rate for Payer: AlohaCare Medicaid	$63.50
Rate for Payer: AlohaCare Medicare	$63.50
Rate for Payer: Cash Price	$82.55
Rate for Payer: Cash Price	$82.55
Rate for Payer: Devoted Health Medicare	$69.85
Rate for Payer: Hawaii Medical Service Association ABD	$14.84
Rate for Payer: Hawaii Medical Service Association Commercial	$13.43
Rate for Payer: Hawaii Medical Service Association Medicare	$63.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.58
Rate for Payer: Hawaii Western Management Group Commercial	$10.74
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Humana Medicare	$63.50
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: Kaiser Permanente Medicaid	$64.77
Rate for Payer: Kaiser Permanente Medicare	$63.50
Rate for Payer: MDX Hawaii PPO	$123.19
Rate for Payer: Ohana Health Plan Medicaid	$63.50
Rate for Payer: Ohana Health Plan Medicare	$63.50
Rate for Payer: UnitedHealthcare Medicaid	$14.84
Rate for Payer: UnitedHealthcare Medicare	$63.50
Rate for Payer: University Health Alliance Commercial	$27.77

Protein Electrophoresis, Urine FSI

Facility

$204.00

Service Code	HCPCS 84166
Hospital Charge Code	8228913
Hospital Revenue Code	301
Min. Negotiated Rate	$17.83
Max. Negotiated Rate	$197.88
Rate for Payer: AlohaCare Medicaid	$102.00
Rate for Payer: AlohaCare Medicare	$102.00
Rate for Payer: Cash Price	$132.60
Rate for Payer: Cash Price	$132.60
Rate for Payer: Devoted Health Medicare	$112.20
Rate for Payer: Hawaii Medical Service Association ABD	$24.92
Rate for Payer: Hawaii Medical Service Association Commercial	$22.29
Rate for Payer: Hawaii Medical Service Association Medicare	$102.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.17
Rate for Payer: Hawaii Western Management Group Commercial	$17.83
Rate for Payer: Health Management Network Commercial	$173.40
Rate for Payer: Humana Medicare	$102.00
Rate for Payer: Kaiser Permanente Commercial	$183.60
Rate for Payer: Kaiser Permanente Medicaid	$104.04
Rate for Payer: Kaiser Permanente Medicare	$102.00
Rate for Payer: MDX Hawaii PPO	$197.88
Rate for Payer: Ohana Health Plan Medicaid	$102.00
Rate for Payer: Ohana Health Plan Medicare	$102.00
Rate for Payer: UnitedHealthcare Medicaid	$24.92
Rate for Payer: UnitedHealthcare Medicare	$102.00
Rate for Payer: University Health Alliance Commercial	$46.10

Protein Electrophoresis, Urine FSI

Facility

$204.00

Service Code	HCPCS 84166
Hospital Charge Code	8228913
Hospital Revenue Code	301
Min. Negotiated Rate	$173.40
Max. Negotiated Rate	$197.88
Rate for Payer: Cash Price	$132.60
Rate for Payer: Health Management Network Commercial	$173.40
Rate for Payer: Kaiser Permanente Commercial	$183.60
Rate for Payer: MDX Hawaii PPO	$197.88

Protein S Activity FSI

Facility

$176.00

Service Code	HCPCS 85306
Hospital Charge Code	8118025
Hospital Revenue Code	305
Min. Negotiated Rate	$15.32
Max. Negotiated Rate	$170.72
Rate for Payer: AlohaCare Medicaid	$88.00
Rate for Payer: AlohaCare Medicare	$88.00
Rate for Payer: Cash Price	$114.40
Rate for Payer: Cash Price	$114.40
Rate for Payer: Devoted Health Medicare	$96.80
Rate for Payer: Hawaii Medical Service Association ABD	$21.18
Rate for Payer: Hawaii Medical Service Association Commercial	$19.15
Rate for Payer: Hawaii Medical Service Association Medicare	$88.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.24
Rate for Payer: Hawaii Western Management Group Commercial	$15.32
Rate for Payer: Health Management Network Commercial	$149.60
Rate for Payer: Humana Medicare	$88.00
Rate for Payer: Kaiser Permanente Commercial	$158.40
Rate for Payer: Kaiser Permanente Medicaid	$89.76
Rate for Payer: Kaiser Permanente Medicare	$88.00
Rate for Payer: MDX Hawaii PPO	$170.72
Rate for Payer: Ohana Health Plan Medicaid	$88.00
Rate for Payer: Ohana Health Plan Medicare	$88.00
Rate for Payer: UnitedHealthcare Medicaid	$21.18
Rate for Payer: UnitedHealthcare Medicare	$88.00
Rate for Payer: University Health Alliance Commercial	$39.61

Protein S Activity FSI

Facility

$176.00

Service Code	HCPCS 85306
Hospital Charge Code	8118025
Hospital Revenue Code	305
Min. Negotiated Rate	$149.60
Max. Negotiated Rate	$170.72
Rate for Payer: Cash Price	$114.40
Rate for Payer: Health Management Network Commercial	$149.60
Rate for Payer: Kaiser Permanente Commercial	$158.40
Rate for Payer: MDX Hawaii PPO	$170.72

Protein Urine Timed FSI

Facility

$63.00

Service Code	HCPCS 84156
Hospital Charge Code	8118026
Hospital Revenue Code	301
Min. Negotiated Rate	$53.55
Max. Negotiated Rate	$61.11
Rate for Payer: Cash Price	$40.95
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: MDX Hawaii PPO	$61.11

Protein Urine Timed FSI

Facility

$63.00

Service Code	HCPCS 84156
Hospital Charge Code	8118026
Hospital Revenue Code	301
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$61.11
Rate for Payer: AlohaCare Medicaid	$31.50
Rate for Payer: AlohaCare Medicare	$31.50
Rate for Payer: Cash Price	$40.95
Rate for Payer: Cash Price	$40.95
Rate for Payer: Devoted Health Medicare	$34.65
Rate for Payer: Hawaii Medical Service Association ABD	$3.69
Rate for Payer: Hawaii Medical Service Association Commercial	$4.59
Rate for Payer: Hawaii Medical Service Association Medicare	$31.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.06
Rate for Payer: Hawaii Western Management Group Commercial	$3.67
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Humana Medicare	$31.50
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Medicaid	$32.13
Rate for Payer: Kaiser Permanente Medicare	$31.50
Rate for Payer: MDX Hawaii PPO	$61.11
Rate for Payer: Ohana Health Plan Medicaid	$31.50
Rate for Payer: Ohana Health Plan Medicare	$31.50
Rate for Payer: UnitedHealthcare Medicaid	$3.69
Rate for Payer: UnitedHealthcare Medicare	$31.50
Rate for Payer: University Health Alliance Commercial	$9.47

prothrombin complex 500 units/20 mL kit [HHSC]

Facility

$3,354.27

Service Code	HCPCS C9132
Hospital Charge Code	2500710
Hospital Revenue Code	250
Min. Negotiated Rate	$2,851.13
Max. Negotiated Rate	$3,253.64
Rate for Payer: Cash Price	$2,180.28
Rate for Payer: Health Management Network Commercial	$2,851.13
Rate for Payer: Kaiser Permanente Commercial	$3,018.84
Rate for Payer: MDX Hawaii PPO	$3,253.64

prothrombin complex 500 units/20 mL kit [HHSC]

Facility

$3,354.27

Service Code	HCPCS C9132
Hospital Charge Code	2500710
Hospital Revenue Code	636
Min. Negotiated Rate	$1,677.13
Max. Negotiated Rate	$3,253.64
Rate for Payer: AlohaCare Medicaid	$1,677.13
Rate for Payer: AlohaCare Medicare	$1,677.13
Rate for Payer: Cash Price	$2,180.28
Rate for Payer: Devoted Health Medicare	$1,844.85
Rate for Payer: Hawaii Medical Service Association Medicare	$1,677.13
Rate for Payer: Hawaii Western Management Group Commercial	$3,186.56
Rate for Payer: Health Management Network Commercial	$2,851.13
Rate for Payer: Humana Medicare	$1,677.13
Rate for Payer: Kaiser Permanente Commercial	$3,018.84
Rate for Payer: Kaiser Permanente Medicaid	$1,710.68
Rate for Payer: Kaiser Permanente Medicare	$1,677.13
Rate for Payer: MDX Hawaii PPO	$3,253.64
Rate for Payer: Ohana Health Plan Medicaid	$1,677.13
Rate for Payer: Ohana Health Plan Medicare	$1,677.13
Rate for Payer: UnitedHealthcare Medicaid	$2,012.56
Rate for Payer: UnitedHealthcare Medicare	$1,677.13
Rate for Payer: University Health Alliance Commercial	$1,878.39

Protime w/ INR FSI

Facility

$67.00

Service Code	HCPCS 85610
Hospital Charge Code	8118027
Hospital Revenue Code	305
Min. Negotiated Rate	$56.95
Max. Negotiated Rate	$64.99
Rate for Payer: Cash Price	$43.55
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: MDX Hawaii PPO	$64.99

Protime w/ INR FSI

Facility

$67.00

Service Code	HCPCS 85610
Hospital Charge Code	8118027
Hospital Revenue Code	305
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$64.99
Rate for Payer: AlohaCare Medicaid	$33.50
Rate for Payer: AlohaCare Medicare	$33.50
Rate for Payer: Cash Price	$43.55
Rate for Payer: Cash Price	$43.55
Rate for Payer: Devoted Health Medicare	$36.85
Rate for Payer: Hawaii Medical Service Association ABD	$5.43
Rate for Payer: Hawaii Medical Service Association Commercial	$5.36
Rate for Payer: Hawaii Medical Service Association Medicare	$33.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.70
Rate for Payer: Hawaii Western Management Group Commercial	$4.29
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Humana Medicare	$33.50
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: Kaiser Permanente Medicaid	$34.17
Rate for Payer: Kaiser Permanente Medicare	$33.50
Rate for Payer: MDX Hawaii PPO	$64.99
Rate for Payer: Ohana Health Plan Medicaid	$33.50
Rate for Payer: Ohana Health Plan Medicare	$33.50
Rate for Payer: UnitedHealthcare Medicaid	$5.43
Rate for Payer: UnitedHealthcare Medicare	$33.50
Rate for Payer: University Health Alliance Commercial	$10.16

PSA, Total FSI

Facility

$139.00

Service Code	HCPCS 84153
Hospital Charge Code	8118028
Hospital Revenue Code	301
Min. Negotiated Rate	$18.39
Max. Negotiated Rate	$134.83
Rate for Payer: AlohaCare Medicaid	$69.50
Rate for Payer: AlohaCare Medicare	$69.50
Rate for Payer: Cash Price	$90.35
Rate for Payer: Cash Price	$90.35
Rate for Payer: Devoted Health Medicare	$76.45
Rate for Payer: Hawaii Medical Service Association ABD	$25.42
Rate for Payer: Hawaii Medical Service Association Commercial	$22.99
Rate for Payer: Hawaii Medical Service Association Medicare	$69.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.69
Rate for Payer: Hawaii Western Management Group Commercial	$18.39
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Humana Medicare	$69.50
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: Kaiser Permanente Medicaid	$70.89
Rate for Payer: Kaiser Permanente Medicare	$69.50
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: Ohana Health Plan Medicaid	$69.50
Rate for Payer: Ohana Health Plan Medicare	$69.50
Rate for Payer: UnitedHealthcare Medicaid	$25.42
Rate for Payer: UnitedHealthcare Medicare	$69.50
Rate for Payer: University Health Alliance Commercial	$47.55

PSA, Total FSI

Facility

$139.00

Service Code	HCPCS 84153
Hospital Charge Code	8118028
Hospital Revenue Code	301
Min. Negotiated Rate	$118.15
Max. Negotiated Rate	$134.83
Rate for Payer: Cash Price	$90.35
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: MDX Hawaii PPO	$134.83

PSA, Total, Medicare Screening FSI

Facility

$145.00

Service Code	HCPCS G0103
Hospital Charge Code	8118029
Hospital Revenue Code	300
Min. Negotiated Rate	$123.25
Max. Negotiated Rate	$140.65
Rate for Payer: Cash Price	$94.25
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: MDX Hawaii PPO	$140.65

Know your out-of-pocket cost for care.

All Charges